CareFirst CHPMD Members: Keep your info current. Keep yourself insured. Medicaid renewals won’t be automatic this year. Check in to make sure your contact information is up to date to receive important notices on any changes to your health insurance. To update your address, phone number or email, log in to your MHC online account. If you need assistance, call MHC at 1-855-642-8572.

CareFirst CHPMD Providers: Encourage your patients to update their information. Find out how you can help your patients renew their coverage here.

Change Healthcare notifying individuals of data breach. Learn more here.

Forms

Click on the form that best meets your needs.

Appeals and Grievance form
Primary Care Provider (PCP) change form
Designation of Personal Representative Form
Notice of Privacy Practices
Prescription Reimbursement Claim Form

Advance Directive:

Advanced Directive Information Sheet
State of Maryland Advance Directive Guide & Forms
CRISP: The State Designated Health Information Exchange (HIE) for Maryland

HIPAA Forms:

HIPAA Authorization
HIPAA Revocation

Protected Health Information:

Request for Access to Protected Health Information (PHI)
Request for Accounting of Protected Health Information (PHI)
Request for Amend or Change Protected Health Information (PHI)
Request for Restriction on Use/Disclosure of Protected Health Information (PHI)